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24/7 Home Care
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(833) 322-7301
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Do you or your loved one need care in Arizona?
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YES
NO
Who Needs Care at Home?
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My Self
Parent
GrandParent
Other Relative
Friend
Other
How Old is the Person Who Needs Care?
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45-54
55-64
65-74
75-84
85 or older
Male or Female?
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Male
Female
What is their current living situation?
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Living Alone at Home
Living at Home with Family
In the Hospital Needs a Sitter
In the Hospital Discharging to Home
Assisted Living
Independent Senior Living
Estimate How Much Care They Might Need
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A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the-Clock Care
Live-In Care
What Type of Care is Needed? (Check all that apply)
Light Meal Preparation
Light Housekeeping
Transportation to Appointments
Errands
Toileting
Respite Care
Light Laundry
Companionship
Grocery Shopping
Bathing
Medication Reminders
Hospice
How will care be paid for?
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Private Funds
Long-Term Care Insurance
Medicaid
Other - (VA Aid and Attendance, Reverse Mortgage, etc)
Zip Code Where Care is Needed
First Name of Person Submitting this Form
Last Name of Person Submitting this Form
Your Email Address- We will send you information via email.
Phone Number of Person Submitting this Form
Additional Comments or Information
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